SARS SINGAPORE EXPERIENCE

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SARS SINGAPORE EXPERIENCE

• 2003 Asia Pacific SARS Prevention Forum
• 29 Sept 2003
• Taipei

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TTSH - Daily Activities
140 Admissions
1,600 SOC Attendances

• 180 Operations
• 42 Inpatients
• 58 Ambulatory

• 360 ED Attendances
• 75 Ambulance Cases

Overview of TTSH
Based on year 2002
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INDEX CASE

• Ms EM,
• 23-yr-old Chinese female
• Was in HK 20-25 Feb 03
• Developed fever and headache since 25 Feb
• Had dry cough on 28 Feb
• Admitted on 1 March

CXR on 1 March 2003
Hsu LY, Leo YS et al
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INDEX CASE

• She progressively worsened while in hospital,
  with persistent fever despite the use of IV
  Levofloxacin.
• Developed hypoxia and required close monitoring
  in HD

Hsu LY, Leo YS et al
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INDEX CASEConclusion

• IV Vancomycin and oral Oseltamivir were added,
  but these did not seem to help
• She finally started improving around 10 March
  2003, and is due for discharge soon

11 March 2003
Hsu LY, Leo YS et al
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Transmission of infection from TTSH, Mar Apr
2003
Index
Ward 5A
TKC
YT
Ward 7D
A
GTL
Ward 8A
J
P
TSC
GTL
TSC
Ward 6A
Community
Heng BH et al
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Mark Chen, Leo YS et al
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Location of transmission (n204)

• No.
• Hospital/Nursing Home 151 74.0
• Household 35 17.2
• Overseas 7 3.4
• Pasir Panjang Wholesale Market 3 1.5
• Community 3 1.5
• Taxi 2 1.0
• Flight 1 0.5
• Undefined 2 1.0

Heng BH et al
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Type of contact (n204)

• No.
• Healthcare worker 84 41.1
• Family 49 24.0
• Inpatients 24 11.8
• Visitors to hospital 19 9.3
• Friends/social contacts 13 6.4
• Imported 7 3.4
• Co-workers in market 3 1.5
• Taxi drivers 2 1.0
• Undefined 2 1.0
• Flight stewardess 1 0.5

Heng BH et al
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Distribution by nationality and gender (n204)
Singaporean 80.8 Filipino 7.8 Chinese
4.9 Indonesian 2.9 Malaysian 2.5 Indian
1.0
Heng BH et al
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7 generations of SARS transmission

• Index
• 1st generation (n21)
• 2nd generation (n39)
• 3rd generation (n79)
• 4th generation (n33)
• 5th generation (n14)
• 6th generation (n4)
• 7th generation (n1)

Imported, 6 cases
Heng BH et al
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Epidemic curve by generations
Heng BH et al
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Age distribution of 204 cases of SARS
Heng BH et al
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SARS Management

• Disease Management
• New pathogen
• Holistic patient care
• Safety of HCWs
• Containment
• Cases detect, insolate, manage
• Expose contact tracing, quarantine
• Prevent travel, personal/environment hygiene
• Planning Ahead

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SARS Management

• Characteristic of New Pathogen
• Incubation
• Mode of transmission
• Infectiousness
• Period of infectiousness
• Case manifestations

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SARS Outbreak ManagementConfronting an Unknown
Enemy

• Time is an essence
• Determine outbreak
• Etiologic agent
• Characteristic of the new disease
• Formulate counter-measure
• Review
• Harness support from all level

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SARS Management

• Containment
• Hospital Infection Control
• SARS intrahospital transmission
• Patient to Patient
• Patient to Staff
• Patient to Visitor
• Staff to Patient
• Staff to Staff
• Community
• Home quarantine
• National
• Border control

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Patient x Staff

• Early identification/detection
• Isolation
• Staff don
• PPE - N95 face mask - glove - goggle - hand
  washing

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Patient x Patient

• Early identification/detection
• Isolation
• Minimise patient movement

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Patient x Visitor

• No visitor
• Video /Teleconference
• Compassionate case, visitor in full PPE

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Staff x Patient
Staff x Staff

• Monitor temperature 3x /D
• Report temperature
• Designated staff clinic
• No external medical leave
• Early isolation if febrile
• Full PPE

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Effectiveness of Barrier Precautions in
Healthcare Workers
Leo YS et al
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Heng BH et al
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Correlation between duration to isolationand
secondary transmission
Interval between date of onset and isolation
Heng BH, Leo YS et al
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16 June 2003
Chen M, Leo YS et al
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SARS Challenges to the Health Care System

• No treatment/no vaccine
• Initial Symptom non specific and common
• Epidemiology/pathogenesis poorly understood
• Diagnostic tests have important limitations
• Affect HCWs vital human resource
• Intensive care strain on health care system

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SARS Management

• Planning Ahead
• Vaccine
• Better diagnostic tools
• Re-define case definition post SARS
• Enhanced surveillance
• Preparedness